Telehealth is a valuable tool for delivering early palliative care to patients with cancer, especially for particularly vulnerable populations such as those with advanced disease. Although the use of telehealth for delivering palliative care does pose unique challenges, according to Jennifer Temel, MD, professor of medicine at Harvard Medical School, these concerns are certainly surmountable, and are not significant barriers when it comes to achieving palliative care goals.
At the 2020 ASCO Quality Care Symposium, Dr Temel discussed practical strategies for utilizing telehealth in palliative care delivery, such as building rapport through good “webside” manner.
Challenges with In-Person Palliative Care
In-person palliative care delivery can pose challenges to patients and their families/caregivers, as well as to clinicians and health systems.
“From the patient perspective, having to see another clinician in the cancer center means added time and fatigue due to multiple appointments,” she said. Family members might need to miss work or take time away from personal obligations to attend physician visits, and they may also face the added financial burden of transportation.
For palliative care clinicians, perhaps the biggest challenge comes down to complex scheduling. “Palliative care clinicians are in demand and are a scarce resource,” she said. “They’re trying to see patients on the same day as the patient’s specialty clinician, and they’re feeling pressured to be in the oncology clinic, the neurology clinic, and the cardiology clinic. So it can be difficult for them to do in-person palliative care in a patient-centered fashion.”
Finally, from a health system perspective, very few outpatient palliative care clinics have the space and resources required to see all of the patients referred to them.
Although these challenges make a good case for telehealth palliative care, certain important factors must also be considered before delivering palliative care in this fashion. Specifically, the lack of ability to use touch to establish rapport and support, as well as the inherent difficulty in broaching the topics being discussed (ie, prognosis and end-of-life care), in addition to more practical considerations like challenges with prescribing opioid analgesics and difficulty controlling the environment (eg, children at home, construction noises).
“Traditionally, discussing these serious topics tends to be through in-person communication,” she said. “So how that type of communication will go with video is somewhat unknown.”
Expanding the Reach of Palliative Care
Dr Temel noted that the first early palliative care study in patients with cancer was in fact a telehealth study. The ENABLE study examined a telephone-based early palliative care model in the outpatient setting, and the intervention demonstrated early and sustained improvements in patient quality of life, mood, and symptoms.
“Obviously, over the last decade or so, we’ve been thinking more about using video instead of telephone to provide medical care to allow for face-to-face engagement,” she said. “So based on our previous work and the ENABLE study, we’re conducting a large comparative effectiveness trial of telehealth using video visits for early palliative care.”
The study, called REACH PC, will seek to determine whether telehealth palliative care is equivalent to in-person palliative care in improving patient quality of life. It will be conducted at 20 sites in 17 states and will involve more than 1000 patients (and their caregivers) with newly diagnosed advanced non–small-cell lung cancer.
Prior to the COVID-19 pandemic, REACH PC had enrolled 581 patients, with 51.7% of approached patients agreeing to participate in the study. “So patients’ acceptance of using video for palliative care was pretty good,” said Dr Temel. “When we looked at the reasons patients declined to participate, very few stated discomfort with technology; instead, most patients said they weren’t interested in research or palliative care.”
Among patients who were successfully recruited, rates of withdrawal (at the time of this analysis) were not significantly different between study groups, reinforcing the hypothesis that patients are interested and willing to consider using video visits.
“Interestingly, about half of the patients in the study are over 60, and one-third are over 70,” she reported. “So while there’s concern about older patients using telehealth, I think these findings show us that they can.”
According to Dr Temel, clinicians involved in the study reported no challenges with video visits the majority of the time. However, clinician comments did tend to echo some of the challenges inherent to conducting palliative care through telehealth: for instance, not being able to physically comfort or provide a tissue to a crying patient, or a patient becoming sick during the session and the clinician being unable to help.
“Interestingly, the proportion of in-person visits with challenges was about the same as telehealth visits, occurring about one-third of the time,” she said. These challenges were mostly delays due to complex scheduling.
But overall, when clinicians were asked whether these challenges hindered their ability to accomplish goals of care for the visit, the answer was “no” the majority of the time in both study arms. “So while telehealth has some challenges and barriers, so does in-person care,” she said.
Dr Temel reminded the audience that telehealth is still relatively new, so there is a learning curve, and certain strategies can help ensure that care is being delivered in accordance with patient/provider goals.
“We’ve coined the phrase ‘webside manner,’ referring to the fact that establishing a relationship and rapport with a patient over video is different,” she said. “But I think a lot of the strategies we use when we’re in front of a patient are the same: using reflective listening, repeating and summarizing their statements, and increasing our nonverbal gestures such as leaning in, nodding, and pausing to make sure we’re not talking over each other.”